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A mass casualty incident (MCI) is any event in which medical resources become overwhelmed by the number and severity of casualties. Large-scale disasters such as earthquakes, hurricanes and terrorist acts are obvious examples of MCIs. Smaller incidents, however, can been equally crippling for a medical facility. A multi-car accident on a remote highway or a local infectious disease outbreak can bring normal hospital operations to a standstill. There is consensus that all hospitals should be ready to manage MCIs from a variety of causes, and ample evidence that many are still not prepared. As illustrated in the recent ASA Monitor article “Be Prepared”1, the medical response to the “Ride the Ducks” MCI at a level 1 trauma center (Harborview Medical Center in Seattle) went smoothly because of planning, practice and staff familiarity with triage and trauma manage-ment. Our medical center is just a few blocks away from Harborview, and it was also involved in caring for some of the victims from the “Ride the Ducks” incident. Like 85 percent of the approximately 5,600 hospitals in the United States, our hospital is not a designated trauma center. We received casualties just the same, and in caring for them multiple defects in our institutional emergency plan became apparent. The truth is that during an MCI any hospital can become a trauma hospital. How then does one start to change the culture of a hospital that has traditionally not viewed itself as part of a community disaster response? In doing so, how do physician anesthesiologists become leaders in hospital emergency preparedness?